DATE OF LOSS:
TYPE OF LOSS:
DATE FORM WAS
General Info: This is an evolving form. Fill it out and provide it to your adjuster on a weekly basis or as FORM 1—Property
frequently as necessary until your claim is resolved. Keep a copy for your files.
__________________________ L O S S I N F O R M ATION
__________________________ Insurance Company and Address: _____________________________________________
Policy Number: Total Square Feet of Structure (s):
Adjuster’s Name and Address: _____________________________________________
Property Address: _____________________________________________
Total Square Feet of Damage: (see Measurements on page 2)
__________________________ Who is your adjuster employed by:
Per Square Foot Cost of Repair to Bring Property to PRE-
__________________________ ____Insurance Co. ____Independent Adjusting Co. EVENT Condition: (see Contractor’s Bid on page 3)
Current Mailing Address:
Name of Independent Co :_________________________
__________________________ Per Square Foot Cost to Replace Property Using LIKE KIND
AND QUALITY: (see Contractor’s Bid on page 3)
Is the Coverage (Policy Limits) Sufficient to Repair or Re-
Date of Adjusters Inspection's: (see log on page 2)
Cell:______________________ place? (Circle One) YES NO
Fax: ______________________ _____________________________________________ Who Set the Policy Limit? (Circle One)
Email: _____________________ POLICYHOLDER AGENT
Areas of Damage Inspected by Adjuster:
_____________________________________________ Is Your Agent an INDEPENDENT AGENT or a CAPTIVE
_____________________________________________ AGENT? _________________________________
(an independent agent sells a number of brands of insurance policies
Coverage Limits _____________________________________________ but a captive agent can sell only one brand)
$__________________ INSPECTION CHECK LIST (To be completed in presence of adjuster )
1. Was structure inspected for safety? Note damage: 6. Was crawl space, pier/beam, or foundation in-
____________________________________ spected? Note damage:
2. Was electrical system inspected for safety? Note
damage: 7. If water entered structure, how many inches from
Unattached Bldgs. ___________________________________ floor was the water?
3. Was HVAC system inspected? Note damage:
Debris Removal ____________________________________ 8. Is mold present on drywall or wood? ________ If
$__________________ so, ask adjuster to make appropriate repairs.
4. Was plumbing inspected? Note damage:
Deductible ____________________________________ 9. Do you need temporary housing?_____
5. Was roof, chimney, attic and garage inspected? 10. Will your adjuster give you an advance to get
Other Note damage: temporary housing or emergency repairs? If so,,
$__________________ ____________________________________ how much? __________________________
Measurements of Damaged Areas
Room Description: Measurement: Damage:
1. 1. 1.
2. 2. 2.
3. 3. 3.
4. 4. 4.
5. 5. 5.
6. 6. 6.
7. 7. 7.
8. 8. 8. Was there food spoilage?
If so, be certain to include
9. 9. 9. spoiled items in your claim.
Were trees destroyed?
Check your policy as there is
probably coverage for lost
MOLD GROWS ON WET shrubs and trees.
AND CAN DEGRADE THE
OF A BUILDING!
Termites and mold love moist
wood, drywall and plywood. Re- POLICYHOLDERS OF AMERICA
move and replace ALL wet 15 Orange Street
wood and drywall immediately Charleston, SC 29401
to avoid this problem! 888-648-8823
We’re a click away:
Date Inspector Notes
POA is a non-profit, consumer
educational organization. We help
policyholders receive the benefits for
which they’ve paid. We are funded
CONTRACTORS POLICYHOLDER ASKED TO BID
Get at least two bids based on the EX-
All Bids Must Be Done On SAME SCOPE OF WORK
ACT scope of work required. Insist that
these bids be BINDING for several
months. And, ask for a BID, not an
ESTIMATE. Bid total: Is bid binding? If so, for how long?
Date contractor can begin:
If architectural plans are needed, you
Estimated completion date:
may need to have the insurer agree to
hire an architect.
Many insurers PAY their
Usually, the policy allows a 20—21% fee Contractor Name:
“preferred contractors” for
for a GENERAL CONTRACTOR if Contact Number:
THREE or more trades are involved. For Bid total: Is bid binding? If so, for how long? ESTIMATES. These contractors
example, if a painter, carpenter, and Date contractor can begin:
may never have any intention
roofer is needed, three trades are in- Estimated completion date:
volved and General Contractor is References:
of doing the work so they
needed to oversee the entire project.
LOWBALL their estimates. Why
Provide written bids to insurance company.
do you think they are
CONTRACTORS SENT OUT BY YOUR INSURANCE COMPANY CONTRACTORS”? Get your
Here’s where it can get squirrelly. The insurance company will attempt to lowball estimates so they can pay less for your claim. own BIDS from qualified, local
More often than not, their estimates are woefully low and are done by contractors PAID to submit the estimate. Be certain
that YOUR contractors bid on an inclusive scope of work and if the insurance company-hired contractor operates on a differ- contractors ready, willing and
ent (or inadequate) scope of work, ask your contractors to put in writing why they feel other repairs are necessary. able to do the work! Also,
INSURANCE CONTRACTOR’S ESTIMATE because of scammers that
swoop down on victims after
disasters, we recommend only
using local contractors with
Date construction to begin by this contractor?
Date construction to be completed by this contractor? roots in your community. I
YOUR DUTIES AND THEIR DUTIES
An insurance policy is a contract the adjuster to be specific about law, lowball your claim, put unrea-
between two parties. You have the what you can do to protect your sonable requirements on you, or
duty to COOPERATE with the property. For example, can you, otherwise gyp you out of the cover-
insurance company (that means be without jeopardizing coverage, rip- age for which you’ve paid.
reasonably available, give reasonable out wet drywall to prevent mold? If
Remember, be firm but respect-
access to your property and pro- so, store all materials you want to
ful. If it all goes to hell in a handbag,
vide documents that are available to discard in large plastic garbage bags
call Policyholders of America at
assist the adjuster). You also have away from the property so the
888-648-8823 for help.
the duty to MITIGATE damage adjuster can inspect the items.
which means protect the property
The insurance company has a
from further damage. If water dam-
duty to fairly and in a timely manner
age has occurred, be certain to ask
adjust your claim. They cannot, by
List any and all documents that the adjuster has asked you to provide, check the
adjusters have the guts to
box next to the document (s) you provided and write the date that you provided
ask policyholders to each document:
produce personal financial
information like tax
returns. Most courts
consider this an invasion
of privacy because your
personal tax returns have
NOTHING to do with the
adjustment of a claim.
You are only required to
helpful in the adjustment ______________________________________________________DATE_______________
of a claim. If you have any
questions, please feel free ______________________________________________________DATE_______________
to contact Policyholders of
America at 888-648- ______________________________________________________DATE_______________
8823 or by email:
List ANY unresolved issue below:
Policyholders of America: Empowering the Policyholder
GRADE YOUR INSURANCE COMPANY:
POLICYHOLDERS Assign a grade (A for excellent, B for above average, C for average, D for below average and F
OF AMERICA for failed miserably) to each of the following:
15 Orange Street Time Period Covered: from ______________________ to ________________________
Charleston, SC 29401
888-648-8823 Applied all coverages available to me in my policy ___________
We’re a click away:
Promptly investigated claim ___________
Thoroughly investigated all aspects of my loss __________
POA is a non-profit, Provided realistic payments to me so I could get the work done ___________
organization. We help Provided payments for LIKE KIND AND QUALITY ____________
policyholders receive the
Encouraged me to use the contractor (s) of my choice ___________
benefits for which they’ve
paid. We are funded Provided prompt payments ____________
exclusively by other
policyholders who have Provided Additional Living Expenses for living quarters comparable to my own home _______
had their own battles with
their own insurance Was helpful, courteous and did not fight me every step of the way ___________
companies and won. We
are not promoters of Did not play “musical adjusters” with me ___________
litigation; in fact, we help Allowed me to honor MY duties under the policy including my duty to mitigate damages _____
litigation by helping them Acted in good faith and dealt with my claim in a professional manner _______
resolve their own claims.
Asked only for information necessary to adjust my claim ________
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